What is scoliosis?

Scoliosis – a lateral (or sideways) curvature of the spine in one or more places – is most frequently seen in children and adolescents. However, adults may also be diagnosed with scoliosis, either when a curve that existed in their youth progresses, or as a de novo (newly diagnosed condition) that can result from degenerative changes in the spine and osteoporosis.

Figures 1-4: Progression of adult scoliosis from age 14 (top left) to age 46 (lower right).

What part of the spine curves in people with scoliosis?

Scoliosis can affect the spine in any of its three major sections:

Cervical spine (neck)

Thoracic spine (chest and upper back region)

Lumbar spine (lower back)

Figure 5: Diagram detailing the sections of the healthy spine, with the neck (cervical) section at the top. The curvature shown in the left image is the normal curve of the spine when it is viewed from the side (not scoliosis). Image courtesy of SpineUniverse.com

What are the symptoms of scoliosis in adults?

Common symptoms

Pain: Adults with scoliosis often experience pain, which leads them to seek medical care. “Pain may be related to the curve itself or due to compression of the spinal nerves,” explains Oheneba Boachie-Adjei, MD, Chief Emeritus of the Scoliosis Service at Hospital for Special Surgery (HSS). The latter condition (compression), is called spinal stenosis. Stenosis can generate inflammation in nerves which, in turn, causes in leg pain and numbness or weakness when walking or standing for a long period of time.

Bulge or deformity in the back: Patients are usually able to point to the site of their back pain, and a bulge may be visible due to muscle rotation or rib cage rotation. Asymmetry in the trunk as it relates to the pelvis may be pronounced.

Additional symptoms experienced by some adults with scoliosis

Loss of height (stature).

Shortness of breath or quick fatigue. This affects patients with large and progressive curves (over 70 degrees) that compress the lungs.

Premature hunger satiety (feeling of fullness). This affects people with progressive, thoracolumbar curves (curves that span the thoracic and lumbar sections of the spine). Associated pressure on the abdomen can make a person feel full while eating, even though the stomach itself is not truly full.

How is adult scoliosis diagnosed?

The medical evaluation for scoliosis includes:

A physical exam.

X-rays taken from the front and side views while the patient stands upright, to accurately measure the degree of the curve.

X-rays taken while the patient bends over in order to assess the flexibility of the curve.

Scoliosis is diagnosed when the curve exceeds 10 degrees. However, by the time adults seek treatment, the curve usually exceeds 30 degrees.

The doctor will also use the physical exam and X-rays to assess the patient for signs of spinal stenosis (the narrowing or compression of the spinal canal). Additional tests may be ordered if there is evidence that the patient's lung function (breathing) is being affected by the scoliosis. In rare cases, patients with a severe scoliosis deformity may develop pulmonary heart disease, which will require evaluation and treatment by additional medical specialists.

“Learning about the patient’s activities of daily living and how their scoliosis symptoms affect their quality of life is another important part of assessment,” notes Dr. Boachie, who adds that this information also helps guide treatment choices.

Patients who continue to experience nerve pin may benefit from steroid injections in the facet joints (where the vertebrae meet at each level of the spine). Steroids, which reduce inflammation, may also be administered by an epidural, in which the injection needle is inserted into the spinal canal to deliver the drugs directly to the affected nerve root.

In some patients experiencing muscle spasms, the doctor may prescribe a brace to be worn on a short-term basis. However, their usefulness is limited since the support they provide gradually weakens the muscles in the trunk and spine.

Surgical treatments

Surgery may be recommended for selected patients, including those who:

Do not respond to non-operative treatment after a period of time

Have curves that exceed 50 degrees and have significant impairment of daily function

Experience worsening lung or neurologic function.

The most common type of surgery in adults is a posterior spinal fusion with instrumentation (artificial implants). In this procedure, the orthopedic surgeon makes an incision from the back and essentially "welds" the vertebrae together using bone chips. These chips may be:

Autografts – taken from elsewhere in the patient's own body.

Allografts – sourced from donors through a bone bank.

The healing process may take a full year or longer. Rods, screws or other implants may be used to hold the spine in alignment during this period. Once the fusion is complete, these implants no longer serve a function but are left in place to avoid the need for additional surgery.

Figures 8-10: Pre-op images of an adult with thoracic scoliosis

Figures 11-13: The same patient after posterior fusion and instrumentation

Depending on the nature of the curve and its location, the orthopedist may need to perform a fusion from both the front and the back of the body, a procedure that may be done as a single operation or in stages.

Figures 14-16: Pre-op images of an adult with lumbar scoliosis

Figures 17-19: The same patient after anterior/posterior (front/back) fusion and instrumentation

Adults with very large and rigid curves may also require osteotomies, in which stiff segments of the facet joints are released.

Some patients with lumbar and thoracolumbar curves may be candidates for thoracoscopic or minimally invasive lateral assess surgery, in which incisions are made from the side of the torso or flank. As with the posterior and anterior approaches, instrumentation corrects the curve and the rotation of the spine. “The thoracoscopic approach offers the advantages of smaller incisions and shorter fusions, which in turn preserves more mobility in the spine,” Dr. Boachie explains.

Adults with scoliosis and spinal stenosis require a decompression procedure in which the roof of the vertebral column is removed at the affected area, freeing the nerve from any material that is compressing it, prior to fusion.

Whenever surgery is considered, the orthopedic surgeon reviews the risks and benefits with the patient, taking into account the person's age and medical history. The presence of other conditions can pose additional surgical challenges, including:

Osteoporosis (a condition in which bone density decreases and the bones become more fragile and likely to break on impact)

Other, non-orthopedic, medical conditions

To address these challenges, surgeons at HSS work with a multidisciplinary team of:

Internists (internal medicine physicians)

Pulmonologists

Neurologists

Anesthesiologists

Orthopedic nurses

Surgical patients are given antibiotics to help guard against infection, and their sensory and motor function is monitored throughout surgery to detect any changes in spinal code integrity during spinal manipulation and curve correction.

Surgical outcomes

In appropriately selected and prepared patients, good outcomes from surgery are achieved, according to Dr. Boachie. Correction of the curve falls in the range of 50% to 80%. Younger, healthier patients tend to have the best results. The SRS 22 patient questionnaire and Oswestry Disability Index (ODI) measure the level of pain relief and improvement of quality of life for each patient.

Complications of scoliosis surgery in adults can include:

Pseudarthrosis (a non-union of the fusion) which may lead to loosening of the implanted instruments

Infections

Neurological problems

Blood clots

Spinal imbalance, which refers to problems with the correction, including the inability of unfused segments to spontaneously correct and balance the spine

Following surgery, most patients remain in the hospital for 5 to 7 days – or slightly longer for those who undergo combined anterior and posterior (front and back) surgery. They are usually back on their feet within two days.

Pain medication is continued as needed. As recovery progresses, patients are advised to limit their activities to walking and to avoid bending and heavy lifting for the first four weeks. By adhering to these guidelines and with the help of physical therapy, the patient should be able to resume normal activities at home by about 4 to 6 weeks. Those with desk jobs may return to work. Adults may take a year or longer to achieve full functional recovery, according to Dr. Boachie, and some adults may still require pain medication for ongoing discomfort.

Patients should be aware that spinal fusion does result in some loss in range of motion; however, the degree varies depending on the site and length of the fusion. If the treatment is primarily in the thoracic spine, normal mobility is achieved after the healing process is completed. If the lumbar spine is the site of treatment, sideways movement will be more restricted, although the patient will still be able to bend forward from the hips. Similarly, fusion in the cervical spine places more restriction on movement.

While surgical treatment of scoliosis in adults can present a complex set of challenges, a team approach and the use of refined surgical techniques and instruments both help ensure a positive outcome. In addition, orthopedic surgeons are increasingly using bone morphogenic proteins (BMPs) in spinal fusions. These substances enhance and accelerate healing for a good long-term result.

If you would like more information about treatment of scoliosis in adults at HSS, please visit our HSS Connect physician referral service or call them 1.877.606-1555. If you live outside the United States, please contact our International Center.